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The inquest heard she was referred to Dr Kara Britz, who works at Tristar Medical in Darwin but hasn't yet passed exams to qualify as a general practitioner.

Dr Britz unknowlingly prescribed half the recommended dose of an anti-anxiety medication and when Ms Di Lembo didn't improve, she stopped taking it all together as she'd lost faith in the drugs ever working.

"It was very concerning for us to learn that the GP that had been recommended to us by the Top End Mental Health Service was a GP in training," Ms Di Lembo's mother Lidia told 9News.

"She had failed her exam nine times. How does that happen?"

Dr Kara Britz gave Sabrina a dosage of medication that would have had little or no effect. (9News)

The family are calling for a list to be made available to the public, publishing the names of qualified mental health GPs.

Ms Di Lembo was never referred to a psychiatrist nor did the psychiatrist at the Top End Mental Health Service (TEMHS) ever agree to see her or her mother in person.

"One of the doctors said that if it had have been Melbourne, he would have recommended that we see a psychiatrist. How can that come out of a doctor's mouth?" Mr Di Lembo said.

"That's my decision.

"You tell me what I need to know then I'll make the decision to take my daughter to Melbourne or anywhere in the world."

TEMHS psychiatrist Dr David Chapman was told of Ms Di Lembo's case and recommended her medication be increased, without ever seeing her.

"What dose is she on currently?" Dr Chapman wrote in an email to a clinician at the mental health service.

"If 37.5mg increase immediately to 75mg (the recommended minimum dosage) and stay on that for one week then increase to 112.5mg until review by Dr Britz.

"Tell mum to stop trying to be a doctor."

Sabrina Di Lembo was studying to be a lawyer. (9News)

Ms Di Lembo and her mother were weary of increasing her medication, as they felt it hadn't been working.

No one told them the dosage she'd previously been prescribed was too low to have an effect.

"I was gobsmacked," Mrs Di Lembo said.

"How dare he?

"Parents know more than anybody what their children are going through.

"I was repeatedly asking questions, as any good parent should.

"And look where we are."

An inquest into Sabrina's death has revealed multiple failures of the NT's mental health system. (9News)

Ms Di Lembo's care was shared by the Top End Mental Health Service, a psychologist and two GPs, but the inquest revealed none of the practitioners took full responsibility for the coordination of her treatment.

Three weeks before her death, Ms Di Lembo spoke to her GP, psychologist and Top End Mental Health Service on the same day.

She gave a different account to each practitioner about how she was feeling, and following a "positive" phone call with TEMHS, her file was closed.

There was no communication with any of the other care providers.

This was major issue for the coroner, whose report today recommended the Top End Mental Health service ensure "all clients are properly assessed" as well as "ensure all other relevent providers are contacted and copies of their last consultations obtained" before a case is closed.

Sabrina was just 19 when she died. (9News)

The coronial findings have highlighted failures in the medical system, where Ms Di Lembo's parents had desperately tried to find help.

NT Minister for Health, Natasha Fyles, told 9News: "The coroner's findings will now be referred to the Department of Health to respond to the recommendations."

"I would like to reassure the Di Lembo family that these recommendations will be taken seriously."

The Di Lembo family is now calling on the government to ensure the coroner's recommendations are implemented, and are considering legal action against the doctors involved.

"Whatever we're doing now if it helps one family and maybe saves one life, that in our heart will never replace our daughter, but it'll be something positive that came out of this," Mr Di Lembo said.

*Readers seeking support and information about suicide prevention can contact Lifeline on 13 11 14.